Pre-op Form

Complete this form if you will be undergoing a procedure and consent to Anaesthesia. This form is required to fulfill the criteria for surgery. All information is sought to minimise your risk and will be retained by the Anaesthetist as part of your confidential clinical record.

Please answer all questions as accurately as possible.

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Do you suffer from or have you suffered from, the following:

Please note:

  • If you have urgent queries, please contact your anaesthetist at his/her room or your surgeon.
  • If your anaesthetist believes there are significant risks identified in this questionnaire, he/she may contact you to make an appointment before surgery and may gather your medical information.
  • Please carry all your medications with you to the hospital / facility.